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Outcomes of a staged surgical treatment strategy for aortoesophageal fistula.

Research paper by Shunsuke S Kawamoto, Mitsuru M Sato, Naotaka N Motoyoshi, Kiichiro K Kumagai, Osamu O Adachi, Takeshi T Saito, Jin J Teshima, Takashi T Kamei, Go G Miyata, Yoshikatsu Y Saiki

Indexed on: 11 Sep '14Published on: 11 Sep '14Published in: General Thoracic and Cardiovascular Surgery



Abstract

Evolution of thoracic endovascular aortic repair (TEVAR) appears to have influenced the pathogenesis and treatment strategy for aortoesophageal fistula (AEF). The purposes of this study are to evaluate our current surgical strategy for AEF and to provide insight to further improve the prognosis of such a devastating condition.Between 2005 and 2013, we retrospectively reviewed the clinical charts of 10 patients requiring surgical treatment for AEF in Tohoku University Hospital. Four cases were primary and 6 were secondary. Initially, bridging TEVAR to control bleeding with concomitant subtotal esophagectomy and complete debridement of infected mediastinal tissue was performed. After a short interval, the patients underwent in situ aortic replacement with cryopreserved homografts or rifampicin-bonded Dacron grafts with omentopexy. Esophageal reconstruction was planned following general physical status improvement after 3-6 months. In-hospital mortality in the acute phase was 30%. Although the completion of the staged strategy achieving successful esophageal reconstruction was possible in 5 patients, no local relapses of infection were observed in these patients. Overall survival at 1 and 5 year were 68.6 and 42.9%, respectively.The staged surgical treatment strategy for AEF consisted of prompt TEVAR to control bleeding with concomitant subtotal esophagectomy and subsequent in situ reconstruction of the aorta with an aortic homograft. This procedure enabled us to control local mediastinal infection with acceptable mortality. Avoiding delay in the diagnosis and initial treatment and resolving complications at each treatment step should further improve AEF treatment.